OTOLOGY

Eustachian tube function in patients with inner ear disorders

Jonas J.-H. Park

Inger Luedeke

Kerstin Luecke

Oliver Emmerling

Martin Westhofen
Received: 16 April 2012 / Accepted: 9 July 2012 / Published online: 2 September 2012
Springer-Verlag 2012
Abstract The inuence of Eustachian tube (ET) dys-
function on the inner ear uid pressure and thus on the inner
ear function in Menieres disease has been discussed con-
troversially. So far, most of the studies examining ET
function in inner ear disorders indirectly analyzed ET
function by tympanometric methods. The present study
directly studied ET function in inner ear disorders by so-
notubometry. Healthy subjects and patients with Menieres
disease, sudden sensorineural hearing loss, cholesteatoma
and chronic suppurative otitis media were examined by
sonotubometry. Mean increase of sound pressure intensity
(dB) and mean duration of sound pressure increase (s) were
analyzed. Highest mean increase of sound pressure intensity
was seen in healthy subjects when using [5 dB peaks
(11.6 0.7 dB) and [0 dB peaks (9.6 0.6 dB). Com-
parative analysis including bilateral ears showed decreased
ET function in patients with cholesteatoma (p = 0.002) and
in patients with Menieres disease (p = 0.003) when using
[0 dB peaks. Examination of each specic ET opening
maneuver showed impaired ET function in pathological
ears of patients with cholesteatoma and with Menieres
disease, during yawning (p = 0.001; p \0.001), dry
swallowing (p = 0.010; p = 0.049), Toynbee maneuver
(p = 0.033; p = 0.032) and drinking (p = 0.044;
p = 0.027). Mild ET dysfunction is detected in patients
with Menieres disease by direct sonotubometric assess-
ment of ET function.
Keywords Eustachian tube function Sonotubometry
Menieres disease Inner ear disorder
Introduction
Eustachian Tube (ET) function is predominately known for
ventilation, drainage and protection against ascending
infection of the middle ear. An indirect effect of ET func-
tion on inner ear function by changing middle ear pressure
has been discussed controversially. The possible involve-
ment of ET function in cochleovestibular disorders has been
proposed by Tumarkin [1]. Supporting observations were
made by other authors, placing a transtympanic ventilation
tube in patients with Menieres disease. Lall [2] reported an
improvement of vertigo after tube insertion and Montandon
et al. [3] noticed a prevention of vertigo attacks. Contrarily,
other studies showed no change of symptoms after venti-
lation tube placement [4]. Different study results might be
due to the diagnostic methods used to assess ET function.
Most of the studies examining ET function in patients with
cochleovestibular disorders only assessed indirectly ET
function by different tympanometric methods in combina-
tion with pressure altering methods [48].
Sonotubometry is an acoustic method to measure ven-
tilatory function of ET. The principle of sonotubometry
was rst described by Politzer [9]. He reported an
increasing sound of a tuning fork held in front of the nostril
when the subject swallowed. During sonotubometric mea-
surements, ET opening is measured by recording changes
of sound pressure level in the external auditory canal; when
a sound is applied to the nostril by a microphone while the
subject actively performs ET opening maneuvers. Virtanen
[10] described the standard procedure for sonotubometry
using frequencies between 6 and 8 kHz. Sonotubometry
J. J.-H. Park (&) I. Luedeke K. Luecke O. Emmerling
M. Westhofen
Department of Otorhinolaryngology and Head and Neck
Surgery, RWTH Aachen University, Pauwelsstrasse 30,
52074 Aachen, Germany
e-mail: jpark@ukaachen.de
1 3
Eur Arch Otorhinolaryngol (2013) 270:16151621
DOI 10.1007/s00405-012-2143-z
allows to evaluate ET function by assessing actual ET
openings.
Until now, there have been no investigations examining
directly ET function in patients with inner ear disorders.
The present study examined ET function in patients with
Menieres disease and with sudden sensorineural hearing
loss by using sonotubometry. ET function was compared to
healthy persons and to patients with known ET dysfunction
such as patients with cholesteatoma and with chronic
suppurative otitis media.
Patients and methods
The prospective study involved 20 healthy persons without
any history of otologic or nasal pathologies (group 1), 16
patients with Menieres disease according to the AAO-HNS
criteria [11] (group 2), 15 patients with sudden sensorineural
hearing loss (group 3), 19 patients with cholesteatoma who
had not received surgical treatment (group 4) and 16 patients
with chronic suppurative otitis media who had not undergone
surgery (group 5). Subjects included in the study were
recruited from January 2008 until August 2008 at the
Department of Otolaryngology of the University Hospital
Aachen. Group 1 consisted of 15 female and 5 male subjects.
The subjects age ranged from20 to 58 years (median = 39).
Group 2 consisted of 7 female and 9 male patients. The
patients age ranged from 44 to 78 years (median = 61).
Group 3 consisted of 10 female and 5 male patients. The
patients age ranged from 31 to 77 years (median = 54).
Group 4 consisted of 6 female and 13 male patients. The
patients age ranged from 35 to 61 years (median = 48).
Group 5 consisted of 5 female and 11 male patients. The
patients age ranged from 32 to 59 years (median = 45.5).
Sonotubometric measurements were performed simul-
taneously for both ears on each subjects. For sonotubo-
metric measurements, a 8 kHz pure tone with an intensity
of 60 dB was delivered by a loudspeaker (Sennheiser KE 4,
Senheiser Corp., Wedemark, Germany) into the nasal
vestibule. The sound generator (DSP EVM 56002, Moto-
rola Corp., Taunusstein, Germany) produced the tone at a
sampling rate of 32 kHz. The tone was recorded by a
microphone (EAR Tone 3A Insert Phone, Interacoustics,
Assens, Denmark) placed in the ipsilateral and contralateral
external ear canal. Before A/D conversion, the signal was
processed in the microphone pre-amplier by a bandpass
lter (fg = 7 kHz) and after A/D conversion by a digital
small bandpass lter (about 8 kHz). Detailed information
of the sonotubometric measuring device are already
described by Di Martino et al. [12].
During sonotubometric measurements, subjects were
instructed to perform ET opening maneuvers which
included yawning, Valsalva maneuver, Toynbee maneuver,
dry swallowing and drinking. Each recording lasted 14 s
and subjects repeated one specic ET opening maneuver
four times. Study design was approved by the ethic com-
mittee of the University Hospital Aachen.
Data were graphically depicted and stored by the soft-
ware program Sonotube with a notebook computer under
Windows XP. Statistical analysis was performed for two
criteria settings. At rst, opening of ET was dened when a
sound level increase of at least 5 dB was registered by the
microphone placed in the external ear canal during ET
opening maneuvers (peak [ 5 dB). Secondly, denition
criteria of ET opening at 5 dB was omitted (peak[0 dB).
For both conditions, mean increase of sound pressure
intensity and mean duration of sound pressure increase
were determined for all ET opening maneuvers together
and separately for each specic ET opening maneuver.
Data from bilateral ears of each person were processed for
theses analysis.
Furthermore, only pathological ears of patients and one
ear side randomly chosen from healthy persons were ana-
lyzed. Comparative studies were performed for all ET
opening maneuver together and separately for each specic
maneuver. Denition criteria peak [0 dB was used for
the last mentioned analysis.
Fig. 1 Mean sonotubometric amplitudes of each group for peaks
[5 dB (a) and for peaks [0 dB (b). 1 healthy persons, 2 Menieres
disease, 3 sudden hearing loss, 4 cholesteatoma, 5 chronic suppurative
otitis media
1616 Eur Arch Otorhinolaryngol (2013) 270:16151621
1 3
Data of each group were compared to each other by
using repeated-measure ANOVA tests (p \0.05). SAS
9.1.3 for Windows was applied for statistical analysis.
Results
Analysis of bilateral ET function for peaks [5 dB
and for peaks [0 dB
Mean sonotubometric amplitudes are shown in Figs. 1 and
2. Mean amplitudes are depicted for each group and for
each ET opening maneuver. Highest mean amplitudes were
seen in healthy persons when using [5 dB amplitudes
(11.6 0.7 dB) (Fig. 1a) and also in healthy persons when
using[0 dB amplitudes (9.6 0.6 dB) (Fig. 1b). Valsalva
maneuver showed the highest mean amplitudes when using
[5 dB amplitudes (11.4 0.6 dB) (Fig. 2a) and also
when using [0 dB amplitudes (8.9 0.6 dB) (Fig. 2b).
Mean sonotubometric amplitudes of every group during
each specic ET opening maneuver using [5 dB ampli-
tudes are presented in Table 1. Mean sonotubometric
amplitudes shown in Table 2 were recorded, when exam-
ining every group during each specic ET opening
maneuver using [0 dB amplitudes.
Results from comparing mean sonotubometric ampli-
tudes of each group for all ET maneuvers included are
depicted in Table 3. When using [5 dB amplitudes for
analysis, only patients with cholesteatoma showed signi-
cantly decreased ET function compared to healthy persons
(Table 3A); whereas when using [0 dB amplitudes also,
ET function of patients with Menieres disease was
impaired (Table 3B).
Interestingly, when every specic ET opening maneuver
was regarded by itself, comparison of each group showed no
signicant differences when using [5 dB amplitudes (data
not shown). Whereas, when using[0 dB amplitudes signi-
cant differences were seen during yawning: decreased
amplitudes were seen in patients with Menieres disease
(p = 0.002), with cholesteatoma (p = 0.005) and with
chronic suppurative otitis media (p = 0.020) compared to
healthy persons. All other data dealing with each specic ET
opening maneuver showed no signicant differences between
the groups, when using peaks[0 dB (data not shown).
Analysis of ET function of only pathological ears
for peaks [0 dB
For comparing healthy persons and pathological ears of
patients, groups [0 dB amplitudes were used which
resulted in following data. Highest mean sonotubometric
amplitudes were seen in group 1 (Fig. 3). Analysis of each
group during each specic ET opening maneuver showed
mean sonotubometric amplitudes presented in Table 4.
Comparative analysis of only pathological ears for all
maneuvers included revealed signicantly decreased
amplitudes in patients with Menieres disease, with sudden
hearing loss and with cholesteatoma compared to healthy
persons (Table 3C).
Fig. 2 Mean sonotubometric amplitudes of each ET opening maneu-
ver for peaks[5 dB (a) and for peaks[0 dB (b). 1 healthy persons, 2
Menieres disease, 3 sudden hearing loss, 4 cholesteatoma, 5 chronic
suppurative otitis media
Table 1 Mean sonotubometric amplitudes (dB) of every group during each specic ET opening maneuver using [5 dB amplitudes
Group 1 Group 2 Group 3 Group 4 Group 5
Yawning 10.1 1.2 6.6 1.8 9.4 1.7 7.9 1.9 10.3 2.2
Dry swallowing 11.8 1.1 10.3 1.7 9.6 1.7 9.2 1.4 12.8 1.8
Toynbee maneuver 12.1 1.1 8.7 1.8 11.4 1.8 9.8 1.5 9.4 1.8
Drinking 9.5 0.8 8.0 1.3 8.2 1.3 8.1 1.0 9.4 1.3
Valsalva maneuver 15.2 1.4 10.9 2.1 11.7 2.1 7.5 2.0 10.0 2.7
1 healthy persons; 2 Menieres disease; 3 sudden hearing loss; 4 cholesteatoma; 5 chronic suppurative otitis media
Eur Arch Otorhinolaryngol (2013) 270:16151621 1617
1 3
The examination of pathological ears regarding each
specic ET opening maneuver separately showed signi-
cantly impaired ET function in patients with Menieres
disease and with cholesteatoma compared to healthy per-
sons during yawning, dry swallowing, Toynbee maneuver
and drinking (Table 5). During Valsava maneuver,
decreased sonotubometric amplitudes were only seen in
patients with cholesteatoma, but not in patients with
Menieres disease. However, patients with sudden hearing
loss also showed ET malfunction during yawning and
drinking (Table 5). ET dysfunction in patients with chronic
suppurative otitis media could only be detected during
yawning.
Any analysis of ET opening time showed no statistically
signicant differences between the groups (data not
shown).
Discussion
During the rst analysis, ET function of bilateral ears in
patients was compared to bilateral ears in healthy persons.
Bilateral ears were involved to assess the overall ET
function of patients with cochleovestibular disorders. The
comparison showed a signicant reduction only in patients
with cholesteatoma compared to healthy persons, when
peaks [5 dB in sonotubometric recordings were regarded
(Table 3A). When considering peaks [0 dB, patients with
Table 2 Mean sonotubometric amplitudes (dB) of every group during each specic ET opening maneuver using [0 dB amplitudes
Group 1 Group 2 Group 3 Group 4 Group 5
Yawning 8.9 0.8 3.2 1.2 4.9 1.2 3.7 1.1 4.1 1.3
Dry swallowing 8.9 1.0 5.3 1.4 6.1 1.5 5.9 1.3 8.7 1.5
Toynbee maneuver 9.5 1.0 5.0 1.6 6.6 1.5 6.4 1.4 6.8 1.6
Drinking 6.5 0.8 4.2 1.1 4.5 1.1 5.1 1.0 5.9 1.2
Valsalva maneuver 12.4 1.3 9.5 2.2 8.6 2.0 5.5 2.0 8.6 2.9
1 healthy persons; 2 Menieres disease; 3 sudden hearing loss; 4 cholesteatoma; 5 chronic suppurative otitis media
Table 3 Comparison of mean
sonotubometric amplitudes for
all ET opening maneuvers
included
(A) Comparison for peaks
[5 dB. (B) Comparison for
peaks [0 dB. (C) Comparison
of only pathological ears for
peaks [0 dB
1 healthy persons; 2 Menieres
disease; 3 sudden hearing loss; 4
cholesteatoma; 5 chronic
suppurative otitis media
n.s. non signicant; s signicant
Groups 1 2 3 4 5
1 n.s. n.s. s. (p=0.043) n.s.
2 n.s. n.s. n.s.
3 n.s. n.s.
4 n.s.
5
A
Groups 1 2 3 4 5
1 s. (p=0.003) n.s. s. (p=0.002) n.s.
2 n.s. n.s. n.s.
3
4
n.s. n.s.
n.s.
5
B
Groups 1 2 3 4 5
1 s. (p=0.003) s. (p=0.010) s. (p<0.001) n.s.
2 n.s. n.s. n.s.
3 n.s. n.s.
4 n.s.
5
C
Fig. 3 Mean sonotubometric amplitudes of healthy persons and of
pathological ears only in patients groups for peaks [0 dB. 1 healthy
persons, 2 Menieres disease, 3 sudden hearing loss, 4 cholesteatoma,
5 chronic suppurative otitis media
1618 Eur Arch Otorhinolaryngol (2013) 270:16151621
1 3
Menieres disease also showed reduced sonotubometric
amplitudes compared to healthy persons (Table 3B). The
separate examination of each ET opening maneuver dis-
played impaired bilateral ET function during yawning in
patients with cholesteatoma and also with Menieres dis-
ease, but not in patients with sudden hearing loss. These
observations indicate an overall ET dysfunction of both
ears in patients with Menieres disease. Since malfunction
of ET could only be found in analysis for sonotubometric
amplitudes [0 dB, ET dysfunction in patients with Meni-
eres disease can be assumed to be rather mild than severe.
Most studies applying sonotubometry dened amplitudes
[5 dB as an ET opening. Using sonotubometric peaks
[0 dB might not be able to distinguish between actual ET
openings from nearly ET openings. Amplitudes [0 dB
might also include artifacts caused by pharyngeal muscle
activities and nose pollution. In fact, not in every case a
denite discrimination between ET opening and artifacts
could be made. Still, including peaks [0 dB might detect
subtle ET dysfunctions which would be missed when
exclusively analyzing peaks [5 dB. Patients with Meni-
eres disease might have an unknown underlying mild ET
Table 4 Mean sonotubometric amplitudes (dB) of healthy persons and pathological ears of patients groups during each specic ET opening
maneuver using [0 dB amplitudes
Group 1 Group 2 Group 3 Group 4 Group 5
Yawning 9.1 0.7 3.0 1.2 4.2 1.4 3.8 1.1 4.1 1.4
Dry swallowing 9.8 0.8 5.5 1.4 5.2 1.6 4.9 1.3 7.9 1.6
Toynbee maneuver 9.8 0.8 4.8 1.5 6.2 1.6 5.4 1.3 7.2 1.7
Drinking 7.5 0.6 3.8 1.1 3.6 1.2 4.2 1.0 5.3 1.2
Valsalva maneuver 12.7 1.0 10.6 2.1 8.7 2.2 5.2 2.0 5.7 3.1
1 healthy persons; 2 Menieres disease; 3 sudden hearing loss; 4 cholesteatoma; 5 chronic suppurative otitis media
Table 5 Comparison of mean
sonotubometric amplitudes for
each specic ET opening
maneuver for peaks [0 dB
Analysis was performed among
pathological ears only in
patients groups and healthy
persons (A) Comparison during
yawning. (B) Comparison
during dry swallowing.
(C) Comparison during
Toynbee maneuver.
(D) Comparison during
drinking. (E) Comparison
during Valsalva maneuver
1 healthy persons; 2 Menieres
disease; 3 sudden hearing loss; 4
cholesteatoma; 5 chronic
suppurative otitis media
n.s. non signicant, s signicant
Groups 1 2 3 4 5
1 s. (p<0.001) s. (p=0.016) s. (p=0.001) s. (p=0.015)
2 n.s. n.s. n.s.
3 n.s. n.s.
4 n.s.
5
A
Groups 1 2 3 4 5
1 s. (p=0.049) n.s. s. (p=0.010) n.s.
2 n.s. n.s. n.s.
3 n.s. n.s.
4 n.s.
5
B
1 s. (p=0.032) n.s. s. (p=0.033) n.s.
2 n.s. n.s. n.s.
3 n.s. n.s.
4 n.s.
5
C
1 s. (p=0.027) s. (p=0.032) s. (p=0.044) n.s.
2 n.s. n.s. n.s.
3 n.s. n.s.
4 n.s.
5
D
Groups 1 2 3 4 5
Groups 1 2 3 4 5
Groups 1 2 3 4 5
1 n.s. n.s. s. (p=0.010) n.s.
2 n.s. n.s. n.s.
3 n.s. n.s.
4 n.s.
5
E
Eur Arch Otorhinolaryngol (2013) 270:16151621 1619
1 3
dysfunction which is clinically not predominant, but which
might effect cochleovestibular function by inuencing
middle ear and thus indirectly inner ear pressure when
present over years. Impaired ET function in patients with
Menieres disease was conrmed by comparing patholog-
ical ears only with healthy persons. Maneuver specic
analysis showed limited ET opening function not only
during yawning, but also during dry swallowing, Toynbee
maneuver and drinking when analyzing affected ears
(Table 5). The fact that rather subtle than predominant ET
dysfunction was found might explain the ndings that only
sonotubometric amplitude was reduced but duration of
opening was not prolonged signicantly in statistical
analysis. It should be mentioned that none of the patients
with inner ear disorders showed micro-otoscopical signs of
middle ear dysventilation.
The inuence of ET function on inner ear function has
been discussed controversially. Abnormal patulous ET was
observed in patients with sudden hearing loss [13] and with
vestibular symptoms [14]. Although pathologically
increased patency of ET could not be conrmed in patients
with cochlear dysfunction by further studies, an inuence
of ET on the inner ear function could not be excluded [15].
Indications of rather decreased patency of ET in patients
with sudden hearing loss were found [15]. Patients with
aural fullness, which is a common symptom of patients
with cochleovestibular defects, showed ET dysfunction
[16]. Whereas several authors found pathological negative
middle ear pressure in patients with Menieres disease [5,
8], others observed no abnormal ndings in tympanometry
in patients with inner ear disturbances [4, 7]. In these
studies, normal tympanometric middle ear pressure was
referred as healthy ET function. However, normal tympa-
nometric results of the middle ear does not necessarily
reveal mild hypo- or dysfunction of ET [16, 17]. Although
tympanometry showed no pathological ndings, ET dys-
function was recorded in tubotympanoaero-dynamic gra-
phy (TTAG) [16].
One reason data of above-mentioned studies about ET
function in patients with Menieres disease [4, 5, 7, 8, 14]
contradict so far might be the predominant usage of tym-
panometric methods. Almost all investigations examining
the role of ET in patients with inner ear disease used
indirect methods by either applying tympanometry alone
[5, 7, 8] or in combination with whole body pressure
chambers [4, 6]. The present study reveals mild ET open-
ing dysfunction in patients with cochleovestibular disorders
by direct evaluation of ET function.
Mechanisms inuencing inner ear pressure by middle
ear pressure changes have been described. Adjacent to the
cochlear aqueduct, a pouch-like extension of the round
window membrane can be found [18]. Depending on the
position of the round window membrane, which is
modied by middle ear pressure, the entrance of the
cochlear aqueduct is opened or closed [19]. Since the
cochlear aqueduct plays a key role in inner ear pressure
regulation [20], inner ear pressure can be altered by middle
ear pressure changes via the described way. Mild persistent
malfunction of ET might lead to intermittent pathologic
middle ear pressure not detected in a single tympanometric
examination, but inuencing inner ear hydrostatic pressure
and therefore inner ear function.
Subtle ET dysfunction might be more advanced on the
affected pathological ear side of patients with inner ear
disease. When comparing overall ET function, which
means comparing bilateral ears, malfunction was only
noticed in patients with concurrent vestibular and cochlear
damages, i.e in Menieres disease, but not in patients with
sudden hearing loss (Table 3B). However, analysis of
affected ears displayed limited ET function also in
patients with isolated cochlear damages (Tables 3C and
5). Further investigations comparing ET function of
pathological and contralateral ear side in patients with
inner ear disorders are needed to examine potential in-
traindividual differences. Such examinations would be
interesting to conduct due to the fact that about 30 % of
patients with Menieres diesease show involvement of
bilateral ears. Still, it remains speculative whether ET
function inuences the pathogenesis of cochleovestibular
diseases. But it is conceivable that in addition to intra-
labyrinthine functional and anatomical abnormalities ET
malfunction might contribute to the development of inner
ear disorders with the clinical appearance of Menieres
syndrome. Long-term middle ear pressure measurements
and if possible inner ear pressure measurements in patients
with inner ear disorders and with sonotubometric proven
ET dysfunction would be helpful for enhanced under-
standing of this matter. Additionally, further studies with
more advanced sonotubometric techniques need to be
performed in patients with Menieres disease. The present
study used a 8 kHz signal for sonotubometry, which is
known to have its limits in sensitivity of detection of ET
opening [12]. It has been shown that so-called perfect
sequences (PSEQ) enhance the sensitivity of sonotubom-
etry [21]. For improved understanding of ET function in
Menieres disease PSEQ should be applied in future
investigations.
Conict of interest None.
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